Ankle Lateral Ligament Reconstruction in Skeletally Immature Patients: Technique Tip.
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ABSTRACT:
SUBMITTER: Chua ENL
PROVIDER: S-EPMC10851733 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Ankle Lateral Ligament Reconstruction in Skeletally Immature Patients: Technique Tip.
Chua Erika Nicole L ENL Jujo Yasuyuki Y Iwashita Kosui K Inagawa Miyu M Lee Keong Joo KJ Takao Masato M
Foot & ankle orthopaedics 20240101 1
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Project description:Pediatric anterior cruciate ligament (ACL) reconstructions have a relatively high risk for re-rupture, and a low proportion of these patients report a successful return to sport. With an increasing emphasis on youth participation in pivoting sports, the incidence of these injuries has increased in recent years. A reappreciation of lateral extra-articular stabilizing procedures in high-risk adult populations who undergo ACL reconstruction has demonstrated potential improved outcomes for vulnerable ACL reconstructions. However, the open status of the pediatric physes makes the use of these procedures more challenging. Therefore, the purpose of this Technical Note is to describe the current authors' surgical technique for a combined ACL reconstruction with a lateral extra-articular tenodesis for these high-risk patients with open physes.
| S-EPMC7372307 | biostudies-literature
Project description:Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the juvenile population. Unfortunately, outcomes with conservative treatment are extremely poor. Adult reconstruction techniques are inappropriate to treat skeletally immature patients because of the risk of physeal complications, including limb-length discrepancy and angular deformities. "Physeal-sparing" reconstruction techniques exist, but their ability to restore knee stability is not well understood. We describe an all-epiphyseal ACL reconstruction for use in skeletally immature patients. This is an all-inside technique with the femoral tunnel drilled retrograde and the tibial tunnel drilled retrograde; both tunnels are entirely within the epiphysis. Fixation of the hamstring autograft is achieved with soft-tissue buttons on both the femur and tibia. We present case examples for 2 patients who underwent the all-inside, all-epiphyseal reconstruction and our postoperative rehabilitation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients.
| S-EPMC3678616 | biostudies-literature
Project description:Patellar instability remains a ubiquitous and troublesome problem in orthopaedics and represents a challenge in the pediatric population. Reconstruction of the medial patellofemoral ligament (MPFL) has become a mainstay of patellar instability management in recent years. As with any procedure at or around the physes, there is concern among surgeons regarding safe placement of hardware and drilled tunnels. The authors describe a technique for anatomic MPFL reconstruction with the aid of fluoroscopic guidance to maintain a "safe zone" without violating the distal femoral physis. This technique allows for reliable MPFL reconstruction in the skeletally immature population with concomitant lateral lengthening, while requiring only minor deviations from the procedure in a skeletally mature patient.
| S-EPMC7301218 | biostudies-literature
Project description:Many techniques have been described for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, including extra-articular, complete or partial transphyseal, and physeal-sparing techniques. An all-epiphyseal technique places the tendon and its tunnels and fixation all within the child's epiphysis, leaving the growth plates untouched. We describe an all-epiphyseal quadruple-hamstring ACL reconstruction using a split tibial tunnel. The split tibial tunnels drop the tunnel size down to 4.5 to 5.5 mm from 7 to 8 mm because only half the total graft diameter passes through each of the split tunnels. This increases the safety margin for keeping the tunnel within the tibial epiphysis, in addition to avoiding damage into the growth plate. The bone bridge between the 2 tunnels serves as a solid low-profile fixation post. Femoral graft fixation is achieved with an interference screw, which allows precise tensioning and low-profile fixation entirely within the femoral tunnel. By placing the graft at the native ACL's anatomic attachment points without spanning or violating the growth plates at any step of the procedure, an all-epiphyseal ACL reconstruction with a split tibial tunnel theoretically minimizes the risk of growth disturbance in an ACL-deficient child.
| S-EPMC3678647 | biostudies-literature
Project description:The number of anterior cruciate ligament (ACL) reconstructions in skeletally immature patients has been gradually increasing in recent years owing to the poor outcomes of conservative treatment. However, ACL reconstruction in children is a challenging procedure and may lead to severe complications, such as growth disturbance. Although double-bundle (DB) ACL reconstructions are preferable because of their superior clinical outcomes, there are few reports of DB ACL reconstruction in children with open epiphyses. In this Technical Note, an all-epiphyseal sparing DB ACL reconstruction technique, which is considered to help avoid growth disturbance, is described. This procedure does not create a thick tunnel and may facilitate subsequent revision surgery.
| S-EPMC7768289 | biostudies-literature
Project description:The medial patellofemoral ligament (MPFL) reconstruction is challenging in skeletally immature patients due to the anatomical particularities at this age. Recently, the medial quadriceps tendon femoral ligament (MQTFL) has received great interest for its ability to restrain the patella's instability along with MPFL. No gold-standard technique has been described so far to reconstruct both MPFL and MQTFL in skeletally immature patients. We present a technique to safely reconstruct the MPFL and the MQTFL in children and adolescents. The gracilis tendon autograft is harvested and passed through the medial collateral ligament as a pulley. The free ends of the graft are passed through the patella by an "L-shaped tunnel" and tied to itself. The other free end of the graft is pulled through the medial third of the quadriceps tendon and tied to itself to achieve tension. Our technique is reproducible, implant-free and avoids complications associated with femoral drilling and graft fixation. However no long-term follow-up results are available.
| S-EPMC9939610 | biostudies-literature
Project description:Graft failure after anterior cruciate ligament reconstruction remains a challenging complication in the pediatric population. The anterolateral ligament (ALL) contributes to rotational stability, and early evidence in adults suggests that ALL reconstruction may lower the risk of anterior cruciate ligament graft rupture. We present a technique for combined ALL reconstruction and anterolateral capsular reinforcement using iliotibial band autograft in skeletally immature patients. This procedure seeks to provide additional rotational stability in varying degrees of flexion while avoiding the physes and eliminating the need for implants.
| S-EPMC7588023 | biostudies-literature
Project description:PurposeTo analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children.MethodsThis study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated.ResultsThirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID.ConclusionsThis series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions.Level of evidenceIV, therapeutic case series.
| S-EPMC9791843 | biostudies-literature
Project description:A technique for anterior cruciate ligament (ACL) reconstruction in patients with open physis is presented. The patient is positioned supine with the knee flexed 90°. After intraarticular injuries are addressed, an autologous hamstring graft is harvested and prepared using a suspension device attached in its expansion device. All-epiphyseal femoral and tibial tunnels of the same diameter of the graft are created; both of them are drilled in an outside-in direction, sparing the physis under radioscopic control. A second divergent tibial tunnel of the same diameter of the graft, distal to the physis, is created in an outside-in, mediolateral, and craniocaudal direction, leaving a 1-cm bone bridge between the 2 tibial tunnels. The graft is passed through the all-epiphyseal tunnels, from femoral to tibial, and pulled until the suspension device leans on the lateral femoral cortex. The graft is passed through the second divergent tibial tunnel and fixed in it with an interference screw to move the pressure away from the physis.
| S-EPMC7301271 | biostudies-literature
Project description:Surgical management of patellofemoral instability is technically challenging in skeletally immature patients. Special considerations in this population include activity and sports limitations, recurrence rate, risk of long-term injury to patellofemoral cartilage, and potential for physeal disruption with operative intervention. Numerous procedures have been described to address causative pathoanatomy in the patellofemoral joint, as well as its static and dynamic stabilizers. We describe our technique of combined medial patellofemoral ligament and modified Roux-Goldthwait reconstruction to address both proximal and distal malalignment in a skeletally immature patient with open physes.
| S-EPMC6928364 | biostudies-literature